Method for predicting and monitoring response to an immune checkpoint inhibitor

ABSTRACT

A method for analyzing cell free DNA (cfDNA) from the bloodstream of a cancer patient is provided. In some embodiments, the method may comprise sequencing at least part of the coding sequences of TP53 and KRAS in a sample of the cfDNA, analyzing the sequences to identify nucleotide transversions in the coding sequences of the genes, relative to reference sequences of the genes. In some embodiments, the method may comprise counting the total number of identified nucleotide transversions. The presence of nucleotide transversions indicates that the patient will be more responsive to the immune checkpoint inhibitor, whereas a decreased number of transversions or no transversios indicates that the patient will be less responsive to the immune checkpoint inhibitor.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.16/013,869, filed on Jun. 20, 2018, which claims the benefit of U.S.Application Ser. No. 62/661,554, filed on Apr. 23, 2018, U.S.Application Ser. No. 62/670,525, filed on May 11, 2018, U.S. ApplicationSer. No. 62/675,655, filed on May 23, 2018, and U.S. Application Ser.No. 62/682,052, filed on Jun. 7, 2018, all of which applications areincorporated by reference herein.

BACKGROUND

The landscape of oncology drug development is rapidly changing with theintroduction of immune-targeting therapies. Specifically, recentapprovals of monoclonal antibodies that target Programmed Death Receptor(PD-1), Programmed Death Ligand 1 (PD-L1) and other immune checkpointshave demonstrated durable clinical benefit across a range of tumorindications. Unfortunately, clinical benefit is limited to a smallfraction of patients highlighting the urgent need for predictivebiomarkers capable of identifying patients most likely to benefit andprevent needless exposure to therapies with associated high costs andpotential of adverse autoimmune effects.

Currently, the overexpression of PD-L1 has been identified as apredictive biomarker for the response to PD-1/PD-L1 targetingantibodies. However, detection of PD-L1 expression by IHC is acontroversial predictive biomarker of which patients may benefit fromtherapy. Several factors have been attributed to why PD-L1immunohistochemical (IHC) staining is limited in its predictive ability.For example, IHC detection methods are sometimes unreliable. PD-L1expression is determined using an anti-PD-L1 antibody by IHC staining offormalin-fixed paraffin-embedded tumor tissue. Staining is confounded byvariable technical factors including pre-analytical factors (propertissue collection, handling, preservation & storage); analytical factors(tissue section thickness, tumor content, staining on non-tumor cells;spatial & temporal limitations of the tissue) and post-analyticalfactors (operation bias in assessing staining intensity; lack ofharmonization in procedures and cut-offs with the 5 available PD-L1companion diagnostic IHC assays). In addition, there is both intra andinter-patient heterogeneity of PD-L1 expression within a given specimenas well as between the primary and metastatic lesion. Finally, PD-L1expression is dynamic and can be induced by activated antigen-specific Tcells, therapeutics and cytokines within the tumor microenvironmentillustrating that evaluation of a single time point may not bereflective of the current responsive state of a tumor to PD-1/PD-L1targeting therapy.

Recently, tumor mutational burden (TMB) (i.e., the total number ofmutations per coding area of a tumor genome) has emerged as a biomarkerof response to anti-PD-1 therapy. Using whole-exome sequencing ofnon-small cell lung cancers treated with pembrolizumab, highernonsynonymous mutation burden in tumors was associated with improvedobjective response, durable clinical benefit, and progression-freesurvival. However, despite the promise of TMB, there are reported caseswhere patients with high TMB fail to respond to PD-1/PD-L1 targetingtherapy as well as patients with low TMB responding to check pointinhibitor therapy.

Other methods, including non-invasive methods, for predicting responseto immune checkpoint inhibitors such as anti-PD-1 or anti-PD-L1antibodies are therefore needed.

SUMMARY

Some embodiments of the present method are based, at least in part, onthe discovery that a cancer patient's response to one or more immunecheckpoint inhibitors such as an anti-PD-1 or anti-PD-L1 antibody can bereliably predicted by whether nucleotide transversions are found in arelatively small number of coding sequences, e.g., the coding sequencesof TP53 and KRAS, and optionally, the coding sequences of CDKN2A andNFE2L2, in cell free DNA obtained from the bloodstream of the patient.An increased number of nucleotide transversions in these genes indicatesthat the patient will be more responsive to the immune checkpointinhibitor, whereas a decreased number of transversions or notransversions in these genes indicates that the patient will be lessresponsive to the immune checkpoint inhibitor.

In some embodiments, the method may involve analyzing cell free DNA(cfDNA) from the bloodstream of a cancer patient. In these embodiments,the method may comprise sequencing at least part of the coding sequencesof TP53 and KRAS (e.g., the coding sequences of TP53, KRAS, CDKN2A andNFE2L2) in a sample of the cfDNA, and analyzing the sequences toidentify nucleotide transversions in the coding sequences of the genes,relative to reference sequences of those genes. In some embodiments, themethod may comprise counting the total number of identified nucleotidetransversions.

In some embodiments, the method may further comprise sequencing at leastpart of the coding sequences of PTEN and STK11 in the sample of cfDNAand analyzing those sequences to determine if there are any loss offunction mutations in those genes. A loss of function mutation in eitherof those genes indicates that the patient will be less responsive orunresponsive to the immune checkpoint inhibitor.

In some embodiments, the method may further comprise sequencing at leastpart of the coding sequences of EGFR and BRAF in the sample of cfDNA todetermine if there are any activating mutations in those genes. Anactivating mutation in either of those genes indicates that the patientwill be less responsive or unresponsive to the immune checkpointinhibitor.

In some embodiments, the method may further comprise determining whetherthere are any rearrangements in ALK and ROS1 in the sample of cfDNA. AnALK rearrangement or ROS1 rearrangement that results in a fusionindicates that the patient will be less responsive or unresponsive tothe immune checkpoint inhibitor.

In some embodiments, the method may comprise providing a reportindicating that there are nucleotide transversions in the genes analyzedand, optionally, whether there are any loss of function mutations inPTEN or STK11, whether there are any activating mutations in EGFR orBRAF and/or whether there are any rearrangements in ALK or ROS1. Thisreport may be forwarded to a third party (e.g., a clinician) at a remotelocation in order to assist them in making a decision on which therapy apatient should be treated with. The method may be most effective onpatients that have non-small cell lung cancer (NSCLC), although themethod may be effective on patients that have other cancers, e.g.,breast cancer etc. In some embodiments, the report may provide a “score”that indicates the likelihood that a patient will be responsive totherapy by an immune checkpoint inhibitor such as an anti-PD-1 oranti-PD-L1 antibody, where the score is based on the analysis summarizedabove and described below. The report may also provide treatmentoptions.

A method for treating cancer is also provided. In some embodiments, thismethod may comprise: determining, in a sample of cfDNA from a cancerpatient: (i) whether there are one or more nucleotide transversions inthe coding sequences of at least TP53 and KRAS; (ii) whether there areany loss of function mutations in PTEN and STK11, (iii), whether thereare any activating mutations in EGFR and BRAF and/or (iv) whether thereare any rearrangements in ALK and ROS1, or receiving a report indicatingthe same; and identifying the patient as a candidate for treatment withan immune checkpoint inhibitor if the patient has one or more nucleotidetransversions in the coding sequences of the TP53 and KRAS, no predictedloss of function mutations in PTEN and STK11, no activating mutations inEGFR and BRAF and no rearrangements in ALK and ROS1.

A method for monitoring treatment of a cancer that has been treated withan immune checkpoint inhibitor is also provided. In some embodiments,this method may comprise: (a) determining the allele frequency of one ormore nucleotide transversions in the coding sequences of at least TP53and KRAS in a sample of cfDNA from a cancer patient at a first timepoint, or receiving a report indicating the same, (b) determining theallele frequency of the one or more nucleotide transversions in thecoding sequences of at least TP53 and KRAS in a sample of cfDNA from thecancer patient at a second time point, or receiving a report indicatingthe same; and (c) comparing the allele frequency of the one or morenucleotide transversions at the first time point to the allele frequencyof the one or more nucleotide transversions at the second time point,thereby monitoring the treatment of the cancer.

In some embodiments, the method may comprise treating a patient with animmune checkpoint inhibitor, wherein the patient is suffering fromcancer, the method comprising: (a) obtaining or having obtained a sampleof blood from the patient; (b) performing or having performed asequencing assay on cell-free DNA (cfDNA) from the sample to determineif the cell-free DNA comprises one or more nucleotide transversions inthe coding sequences of TP53 and KRAS, relative to reference sequencesof the TP53 and KRAS; and (c) if the patient has one or more nucleotidetransversions in the coding sequences of the TP53 or KRAS, thenadministering an effective amount of the immune checkpoint inhibitor tothe patient. In these embodiments, the sequencing assay may furtherdetermine if the cell-free DNA may comprise determining if there are oneor more nucleotide transversions in the coding sequences of CDKN2A andNFE2L2.

In some embodiments, the method may comprise (a) obtaining or havingobtained a sample of blood from the patient; (b) performing or havingperformed a sequencing assay on cell-free DNA (cfDNA) from the sample todetermine if the cell-free DNA comprises: i. nucleotide transversions inthe coding sequences of TP53 and KRAS, relative to reference sequencesof TP53 and KRAS, and ii. predicted loss of function mutations in PTENand STK11, iii. activating mutations in EGFR and BRAF, and ivrearrangements in ALK and ROS1; and (c) if the patient has one or morenucleotide transversions in the coding sequences of TP53 and KRAS, nopredicted loss of function mutations in PTEN and STK11, no activatingmutations in EGFR and BRAF and no rearrangements in ALK and ROS1, thenadministering an effective amount of the immune checkpoint inhibitor tothe patient.

In any embodiment, the sequencing assay may comprise: sequencing atleast part of the coding sequences of TP53, KRAS, and, optionally,CDKN2A and NFE2L2 in the sample of cfDNA and analyzing the sequences todetermine if there are any transversions in TP53, KRAS, and, optionally,CDKN2A and NFE2L2, sequencing at least part of the coding sequences ofPTEN and STK11 in the sample of cfDNA and analyzing the sequences todetermine if there are any loss of function mutations in PTEN and STK11,sequencing at least part of the coding sequences of EGFR and BRAF in thesample of cfDNA and analyzing the sequences to determine if there areany activating mutations in EGFR or BRAF; and sequencing at least partof ALK and ROS1 in the sample of cfDNA and analyzing the sequences todetermine if there are any rearrangements in ALK and ROS1, in the sampleof cfDNA.

In any embodiment, the patient may have non-small cell lung cancer(NSCLC).

In all embodiments, the genes referenced in the determining steps aremeant to be collective in the sense that if the method determines ifthere are one or more nucleotide transversions in the coding sequencesof TP53 and KRAS, then the sequences of both TP53 and KRAS are analyzedand, if either or both of those genes contain a nucleotide transversionthen the one or more nucleotide transverions are identified in TP53 andKRAS. In other words, in order for there to be one or more nucleotidetransversions in TP53 and KRAS, a nucleotide transversion can be foundin one gene, the other gene, or both genes. This wording is not meant tobe interpreted as requiring that a nucleotide transversion must be foundin both genes. Likewise, there is a predicted loss of function mutationin PTEN and STK11 if either or both of those genes contains a predictedloss of function mutation; there is an activating mutation in EGFR andBRAF if either or both of these genes contain an activating mutation,and there is a rearrangement in ALK and ROS1 if either of those geneshas been rearranged.

These and other features of the present teachings are set forth herein.

BRIEF DESCRIPTION OF THE FIGURES

The skilled artisan will understand that the drawings, described below,are for illustration purposes only. The drawings are not intended tolimit the scope of the present teachings in any way.

FIG. 1 is a flow chart illustrating an exemplary implementation of themethod. In this flow chart, Y=Yes, N=No, NR indicates a patient that ispredicted to not respond to immune checkpoint inhibition (i.e., anon-responder). These patients can be classified as having a “Low”score. R indicates a patient that is predicted to respond to immunecheckpoint inhibition (i.e., a responder). These patients can beclassified as having a “High” score. As would be apparent, the steps ofthis method could be performed in a different order or with differentcomponents.

FIG. 2 provides examples of the ability of the sequencing workflow usedto identify and differentiate specific genomic alterations(transversions vs transitions) in the target genes. Furthermore,response to clinical intervention with PD-1/PD-L1 targeting therapiescorrelated with the presence of these specific alterations with benefitbeing derived when those alterations where transversion in nature andlack of clinical benefit demonstrated when the alterations were due totransitions or alterations in STK11 were present.

FIG. 3 shows a Kaplan-Meier plot of patients with a High score (X) orLow score (Y).

FIG. 4 shows mutant allele frequencies monitored throughout treatment ina patient who demonstrated progressive disease while on therapy withatezolimumab.

FIG. 5 shows the mutant allele frequencies monitored throughouttreatment in a patient who demonstrated a clinical partial responsewhile on therapy with nivolumab.

DEFINITIONS

Before describing exemplary embodiments in greater detail, the followingdefinitions are set forth to illustrate and define the meaning and scopeof the terms used in the description.

Numeric ranges are inclusive of the numbers defining the range. Unlessotherwise indicated, nucleic acids are written left to right in 5′ to 3′orientation; amino acid sequences are written left to right in amino tocarboxy orientation, respectively.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Singleton, et al., DICTIONARYOF MICROBIOLOGY AND MOLECULAR BIOLOGY, 2D ED., John Wiley and Sons, NewYork (1994), and Hale & Markham, THE HARPER COLLINS DICTIONARY OFBIOLOGY, Harper Perennial, N.Y. (1991) provide one of skill with thegeneral meaning of many of the terms used herein. Still, certain termsare defined below for the sake of clarity and ease of reference.

It must be noted that as used herein and in the appended claims, thesingular forms “a”, “an”, and “the” include plural referents unless thecontext clearly dictates otherwise. For example, the term “a primer”refers to one or more primers, i.e., a single primer and multipleprimers. It is further noted that the claims can be drafted to excludeany optional element. As such, this statement is intended to serve asantecedent basis for use of such exclusive terminology as “solely,”“only” and the like in connection with the recitation of claim elements,or use of a “negative” limitation.

A “plurality” contains at least 2 members. In certain cases, a pluralitymay have at least 10, at least 100, at least 100, at least 10,000, atleast 100,000, at least 10⁶, at least 10⁷, at least 10⁸ or at least 10⁹or more members.

The term “sequencing,” as used herein, refers to a method by which theidentity of at least 10 consecutive nucleotides (e.g., the identity ofat least 20, at least 50, at least 100 or at least 200 or moreconsecutive nucleotides) of a polynucleotide is obtained.

The terms “next-generation sequencing” or “high-throughput sequencing”,as used herein, refer to the so-called parallelizedsequencing-by-synthesis or sequencing-by-ligation platforms currentlyemployed by Illumina, Life Technologies, and Roche, etc. Next-generationsequencing methods may also include nanopore sequencing methods such asthat commercialized by Oxford Nanopore Technologies,electronic-detection based methods such as Ion Torrent technologycommercialized by Life Technologies, or single-moleculefluorescence-based methods such as that commercialized by PacificBiosciences.

The term “sequencing at least part of the coding sequences” referssequencing at least 20% of, at least 40% of, at least 60% of, at least80% of, or at least 90% of (e.g., all of), of the coding sequences.

The term “reference sequence”, as used herein, refers to a knownnucleotide sequence, e.g. a chromosomal region whose sequence isdeposited at NCBI's Genbank database or other databases, for example. Areference sequence can be a wild type sequence.

As used herein, the terms “cell-free DNA from the bloodstream” and“circulating cell-free DNA” refers to DNA that is circulating in theperipheral blood of a patient. The DNA molecules in cell-free DNA mayhave a median size that is below 1 kb (e.g., in the range of 50 bp to500 bp, 80 bp to 400 bp, or 100-1,000 bp), although fragments having amedian size outside of this range may be present. Cell-free DNA maycontain circulating tumor DNA (ctDNA), i.e., tumor DNA circulatingfreely in the blood of a cancer patient or circulating fetal DNA (if thesubject is a pregnant female). cfDNA can be obtained by centrifugingwhole blood to remove all cells, and then isolating the DNA from theremaining plasma or serum. Such methods are well known (see, e.g., Lo etal, Am J Hum Genet 1998; 62:768-75). Circulating cell-free DNA can bedouble-stranded or single-stranded.

As used herein, the term “circulating tumor DNA” (or “ctDNA”) istumor-derived DNA that is circulating in the peripheral blood of apatient. ctDNA is of tumor origin and originates directly from the tumoror from circulating tumor cells (CTCs), which are viable, intact tumorcells that shed from primary tumors and enter the bloodstream orlymphatic system. The precise mechanism of ctDNA release is unclear,although it is postulated involve apoptosis and necrosis from dyingcells, or active release from viable tumor cells. ctDNA can be highlyfragmented and in some cases can have a mean fragment size about 100-250bp, e.g., 150 to 200 bp long. The amount of ctDNA in a sample ofcirculating cell-free DNA isolated from a cancer patent varies greatly:typical samples contain less than 10% ctDNA, although many samples haveless than 1% ctDNA and some samples have over 10% ctDNA. Molecules ofctDNA can be often be identified because it contains tumorigenicmutations.

As used herein, the term “nucleotide transversion” refers to thesubstitution of a purine nucleotide (e.g., an A or G) with a pyrimidinenucleotide (e.g., a T or C), or substitution of a pyrimidine nucleotide(e.g., a T or C) with a purine nucleotide (e.g., an A or G). Nucleotidetransversions include A to T, T to A, A to C, C to A, G to T, T to G, Gto C and C to G transversions.

Other definitions of terms may appear throughout the specification.

DESCRIPTION OF EXEMPLARY EMBODIMENTS

Before the various embodiments are described, it is to be understoodthat the teachings of this disclosure are not limited to the particularembodiments described, and as such can, of course, vary. It is also tobe understood that the terminology used herein is for the purpose ofdescribing particular embodiments only, and is not intended to belimiting, since the scope of the present teachings will be limited onlyby the appended claims.

The section headings used herein are for organizational purposes onlyand are not to be construed as limiting the subject matter described inany way. While the present teachings are described in conjunction withvarious embodiments, it is not intended that the present teachings belimited to such embodiments. On the contrary, the present teachingsencompass various alternatives, modifications, and equivalents, as willbe appreciated by those of skill in the art.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this disclosure belongs. Although any methods andmaterials similar or equivalent to those described herein can also beused in the practice or testing of the present teachings, the someexemplary methods and materials are now described.

The citation of any publication is for its disclosure prior to thefiling date and should not be construed as an admission that the presentclaims are not entitled to antedate such publication by virtue of priorinvention. Further, the dates of publication provided can be differentfrom the actual publication dates which can need to be independentlyconfirmed.

As will be apparent to those of skill in the art upon reading thisdisclosure, each of the individual embodiments described and illustratedherein has discrete components and features which can be readilyseparated from or combined with the features of any of the other severalembodiments without departing from the scope or spirit of the presentteachings. Any recited method can be carried out in the order of eventsrecited or in any other order which is logically possible.

All patents and publications, including all sequences disclosed withinsuch patents and publications, referred to herein are expresslyincorporated by reference.

A method for analyzing cell free DNA (cfDNA) from the bloodstream of acancer patient is provided. As noted above, the method may comprisesequencing at least part of the coding sequences of TP53 and KRAS (andpotentially other genes such as PTEN, STK11, EGFR, BRAF, CDKN2A, NFE2L2)and, optionally, as well as at least part of ALK and ROS1 in a sample ofthe cfDNA. Methods for sequencing target sequences in cfDNA are knownand, in some embodiments, the method may comprise enriching for oramplifying target sequences by PCR prior to sequencing (see, e.g.,Forshew et al, Sci. Transl. Med. 2012 4:136ra68, Gale et al, PLoS One2018 13:e0194630 and Weaver et al, Nat. Genet. 2014 46:837-843, amongmany others). ALK and ROS1 fusions may be identified using similarmethods, e.g., using PCR and the sequenceing the products. These methodmay make use of primer pairs in which one primer hybridizes to the ALKor ROS1 gene and another primer hybridizes to a gene encoding apotential fusion partner for ALK or ROS1. In some embodiments, themethod does not involve shotgun sequencing an unenriched/unamplifiedsample, or sequencing the entire exome. Rather, the sequencing may bedone as part of a larger sequencing effort that targets at least part ofthe coding sequences for up to 200, e.g., up to 100 or up to 50 genes,focusing on the coding sequences of TP53 and KRAS (and potentially othergenes such as PTEN, STK11, EGFR, BRAF, CDKN2A, NFE2L2) as well asothers).

After the sequences have undergone initial processing, the sequences areanalyzed to identify nucleotide transversions. This may be done bycomparing the test sequence to a reference sequence, for each sequencebeing analyzed, and the identifying positions that contain a purine topyrimidine substitution or pyrimidine to purine substitution. In somecases, this may comprise calling mutations de novo (e.g., using themethod described by Forshew, supra, or another suitable method) and thendetermining which of those mutations are nucleotide transversions (asopposed to nucleotide transitions). Calling sequence variations incell-free DNA can be challenging because the variant sequences aregenerally in the minority (e.g., less than 10% of the sequence). Assuch, if an amplicon sequencing strategy is employed, the method maycomprise: (a) for each nucleotide position of a particular amplicon,determining, e.g., plotting, an error distribution that shows how oftenamplification and/or sequencing errors occur at different sequencingdepths; (b) based on the distribution for each position of the sequence,determining a threshold frequency for each different sequencing depth ator above which a true genetic variation can be detected; (c) sequencingthe sample to obtain plurality of reads for an amplicon; anddetermining, for each position of the amplicon, whether the frequency ofa potential sequence variation in the sequence reads is above or belowthe threshold. Mutation may be identified (or “called”) at a position ifthe frequency of sequence reads that contain the variation is above thethreshold. In some cases, a substitution may be identified only if itoccurs in the same amplicon from multiple independent amplificationreactions. As would be apparent, if the sequencing is done using anamplicon approach, the method may comprise amplifying the codingsequences of the genes in a multiplex PCR reaction in which at least 10amplicons (e.g., more than 10 and less than 50,000 amplicons, more than10 and less than 10,000, more than 10 and less than 5,000 amplicons,more than 10 and less than 1,000 amplicons or more than 10 and less than500 amplicons) or more than 10 and less than 100 amplicons are amplified(in duplicate, triplicate or quadruplicate, for example) and sequencingthe amplicons. More or less amplicons can also be sequenced, if needed.In some embodiments, the primers used for amplification may not becompletely specific for a single sequence, which can allow severalhundred or several thousand amplicons to be consistently amplified in asingle reaction. The amplicons sequenced can be of any suitable lengthand may vary in length. In some embodiments, the length of eachamplicon, independently, may be in the range of 50 bp to 500 bp,although longer or shorter amplicons may be used in someimplementations.

Next, the nucleotide transversions are identified and, in someembodiments, counted. The presence of nucleotide transversions in thecoding sequences of TP53 and KRAS (and, optionally, CDKN2A and NFE2L2)in cfDNA correlates with the patient's response to immune checkpointinhibition (e.g., PD-1 or PD-L1 blockade) and, as such, the presence ofnucleotide transversions (or a score representing the same) in at leastpart of the coding sequences of TP53 and KRAS can be used to predictwhether the patient will be susceptible to immune checkpoint inhibition.Identifying nucleotide transversions may comprise identifying A to Ctransversions, identifying C to A transversions, identifying G to Ttransversions, identifying T to G transversions, identifying A to Ttransversions, identifying T to A transversions, identifying G to Ctransversions and identifying C to G transversions. In some embodiments,the total number of nucleotide transversions may be counted.

In some embodiments, the method may comprise sequencing at least part ofthe coding sequences of TP53, KRAS, CDKN2A and NFE2L2 in the sample ofcfDNA, and determining whether there are any nucleotide transversions inthe coding sequences of those genes.

In some embodiments, the transversions may be identified de novo, i.e.,without any expectation that they occur at a particular position orpositions.

In some embodiments, the method may further comprise sequencing at leastpart of the coding sequences of PTEN and STK11 (also known as liverkinase B1 (LKB1) and renal carcinoma antigen NY-REN-19) in the sample ofcfDNA, and analyzing the sequences to determine if there are any loss offunction mutations in the genes. Examples of loss of function mutationsinclude, but are not limited to mutations that generate a stop codon,mutations at splice junctions, and mutations that substitute a criticalamino acid for another. The proteins encoded by these genes are wellcharacterized (see, e.g., Worby et al, Annu. Rev. Biochem. 201483:641-69 and Zeqiraj et al, Science 2009 326: 1707-11), and they belongto well characterized families. As such, it should be relativelystraightforward identify important or critical residues in thoseproteins. The presence of a loss of function mutation in either of thesegenes indicates that the patient would not be responsive to immunecheckpoint blockade. As such, if there are no predicted loss of functionmutations in PTEN or STK11, then the patient should be susceptible toimmune checkpoint inhibition.

In some embodiments, the method may further comprise sequencing at leastpart of the coding sequences of EGFR and BRAF and determining whetherthere are any rearrangements in ALK and ROS1 that would result in theproduction of a fusion protein. In subsets of patients with NSCLC,tumors harbor activating genomic alterations in the corresponding kinaseregion of genes including EGFR and BRAF that result in constitutiveactivation and have been identified as driver mutations (see, e.g.,Gridelli et al, Nat Rev Dis Prim. 2015, which is incorporated byreference herein). Activating mutations for EGFR include, but are notlimited to: G719X; Exon19 deletions; V765A; T783A; V774A; S784P; L858R &L861X. Activating mutations for BRAF include, but are not limited to:V600E; L601G; K601E; L597V/Q/R and G469V/S/R/E/A). Additionally,chromosomal rearrangements between both ALK and ROS1 and fusionpartners, have been identified as drivers. This results from either ALKor ROS1's kinase domain being put under the control of a new promoter.Variants include EML4-ALK, TFG-ALK, KIFSB-ALK, CD74-ROS1, SLC34A2-ROS1,SDC4-ROS1 and EZR-ROS1. Targeted therapies directed against theseactivating alterations in EGFR, ALK, ROS1 and BRAF have been approvedfor use in patients harboring these activating mutations and fusions,and thus, these are described as “actionable” mutations. NSCLC patientsharboring EGFR and BRAF activating mutations or ALK rearrangements arebelieved to be associated with low overall response rates to PD-1/PD-L1inhibitors. As such, in some embodiments, the patient may be assessedfor actionable mutations EGFR, ALK, ROS1 and BRAF. If such a mutation isdetected then a PD-1/PD-L1 immune checkpoint inhibitor is notadministered. Rather a therapy that is appropriate for the mutation maybe administered. For example, erlotinib (Tarceva), afatinib (Gilotrif),gefitinib (Iressa) or osimertinib (Tagrisso) may be administered topatients having an activating mutation in EGFR, crizotinib (Xalkori),ceritinib (Zykadia), alectinib (Alecensa) or brigatinib (Alunbrig) maybe administered to patients having an an ALK fusion, crizotinib(Xalkori), entrectinib (RXDX-101), lorlatinib (PF-06463922), crizotinib(Xalkori), entrectinib (RXDX-101), lorlatinib (PF-06463922),ropotrectinib (TPX-0005), DS-6051b, ceritinib, ensartinib orcabozantinib may be administered to patients having an an ROS lfusion,and dabrafenib (Tafinlar) or trametinib (Mekinist) may be administeredto patients having an activating mutation in BRAF. In any embodiment,the activating mutations in EGFR and BRAF may comprise: G719X, exonl9deletions, V765A, T783A, V774A, S784P, L858R and L861X in EGFR andV600E; L601G; K601E; L597V/Q/R and G469V/S/R/E/A in BRAF. Likewise, inany embodiment the rearrangements in ALK and ROS1 may comprise EML4-ALK,TFG-ALK, KIF5B-ALK, CD74-ROS1, SLC34A2-ROS1, SDC4-ROS1 and EZR-ROS1fusions.

A patient that, based on the analysis of the patient's cell-free DNA,appears to be EGFR activating mutation-negative, BRAF activatingmutation-negative, ALK rearrangement-negative and ROS1rearrangement-negative and has one or more nucleotide transversions inthe coding sequences of TP53 and KRAS and no predicted loss of functionmutations in PTEN or STK11 may be treated with an immune checkpointinhibitor.

In alternative embodiments, any of the methods described or claimedabove or below can be practiced on DNA isolated from a tissue biopsy,e.g., a section of tissue, an aspirate, or a sample of cells collectionof a tumor. In some embodiments, the biopsy may comprise cells or atissue sample of lung, e.g., a site or circulating or migrating cells ofNSCLC. The sample may include any extract or partial or wholefractionation of cell or tissue sample of lung, e.g., on site orcirculating or migrating cells of NSCLC.

In some embodiments, the method may further comprise sequencing a set ofnon-coding sequences, and, in some cases, counting the total number ofnucleotide transversions in those sequences.

A flow chart illustrating an exemplary implementation of the method isshown in FIG. 1. In this implementation, after sequencing cfDNA, thesequences are analyzed to determine if there is any circulating tumorDNA in the cfDNA. ctDNA can be identified because it contains relativelylow frequency mutations (e.g., less than 10% and occasionally higher).If there is no ctDNA is detected in the cfDNA, then the patient may beindicated as an “indeterminant”, which indicates that it isunpredictable whether the patient will respond or will not resond to anytargeted therapy or immune checkpoint inhibition. In the implementationshown, the sequences may be screened for actionable mutations (i.e.,mutations in genes such as, e.g., EGFR, BRAF, ALK and ROS1, as describedabove, for which a target treatment is already available). Cancersassociated with these mutations are generally not responsive to immunecheckpoint inhibition unless there is a nucleotide transversion in KRASor TP53. If there are no actionable mutations EGFR, BRAF, ALK and ROS1,then the sequences for PTEN and STK11 can be screened for loss offunction mutations. If there are no predicted loss of function mutationsin PTEN and STK11, then the presence of nucleotide transversions (or ascore representing the same) in the coding sequences of TP53 and KRAS(and, optionally, CDKN2A and NFE2L2) are determined. If nucleotidetransversions are identified or if the total number of nucleotidetransversions is above a threshold, then the patient should be indicatedas being responsive to immune checkpoint inhibition. Other nucleotidechanges may contribute to the decision about whether a patient may beindicated as being responsive to immune checkpoint inhibition, inaddition to those described above. In some embodiments, results obtainedfrom this workflow may be expressed as a “score”.

A brief description of some of the genes that can be analyzed in thismethod is set forth below.

TP53 is the gene that encodes the tumor suppressor p53. In humans, theTP53 gene is located on the short arm of chromosome 17 (17p13.1). Thegene spans 20 kb, with a non-coding exon 1 and a very long first intronof 10 kb. The coding sequence contains five regions showing a highdegree of conservation in vertebrates, predominantly in exons 2, 5, 6, 7and 8. TP53 orthologs have been identified in most mammals for whichcomplete genome data are available. In humans, a common polymorphisminvolves the substitution of an arginine for a proline at codon position72. Many studies have investigated a genetic link between this variationand cancer susceptibility. See, e.g., Matlashewski et al, The EMBOJournal. 1984 3: 3257-62. The sequence of the human TP53 gene and itsstructure are set forth in entry 7157 in NCBI's gene database; NCBIReference Sequence: NG_017013.2.

KRAS is a Kirsten ras oncogene homolog from the mammalian ras genefamily and encodes a protein that is a member of the small GTPasesuperfamily. Several mutations are known can activate this protein (see,e.g., Karachaliou et al Clin Lung Cancer. 2013 14: 205-14). Alternativesplicing leads to variants encoding two isoforms that differ in theC-terminal region. KRAS is also known as K-Ras 2, Ki-Ras, c-K-ras, andc-Ki-ras. Human cells harbor the KRAS gene at chromosomal band 12p12.1.See, e.g., Tsuchida et al, Oncotarget. 2016 7: 46717-33. The sequence ofthe human KRAS gene and its structure are set forth in entry 3845 inNCBI's gene database; NCBI Reference Sequence: NG_007524.1.

BRAF is the human gene that encodes a protein called B-Raf. The gene isalso referred to as proto-oncogene B-Raf and v-Raf murine sarcoma viraloncogene homolog B, while the protein is more formally known asserine/threonine-protein kinase B-Raf. The BRAF gene is located onchromosome 7q34, and covers approximately 190 kb. It contains at least19 exons and encodes a full-length transcript of 2,510 bp (NM_00433). Atleast seven variant transcripts have been identified, which are productsof alternative splicing. From these various transcripts, severalproteins are translated, including the full-length, 94-95 kD, 783 aminoacid product. See, e.g., Sithanandam et al, Oncogene 1990 5: 1775-80;and Meyer et al Journal of Carcinogenesis 2003 2, 7. The sequence ofhuman BRAF and its structure are set forth in entry 673 in NCBI's genedatabase; NCBI Reference Sequence: NG_007873.3.

EGFR encodes a transmembrane glycoprotein that is a member of theprotein kinase superfamily. The gene maps to 7p11.2. The EGFR genecontains 28 exons and spans nearly 200 kb. Intron 1 spans 123 kb. Thegene contains several repeat elements, including SINEs and LINEs, aswell as a trinucleotide (TGG/A) repeat-rich region in intron 15, and 2long CA repeats in intron 27. The sequence of the human EGFR gene andits structure are set forth in entry 1956 in NCBI's gene database; NCBIReference Sequence: NG_007726.3. See, e.g., Zhang et al J Med Genet.2007 44: 166-72.

ALK encodes a receptor tyrosine kinase, which belongs to the insulinreceptor superfamily. ALK is situated on the short arm of chromosome 2(2p23.2). The gene contains over 30 distinct introns and transcriptionproduces about 8 different mRNAs, with several alternatively splicedvariants and unspliced forms. The sequence of the human ALK gene and itsstructure are set forth in entry 427 in NCBI's gene database; NCBIReference Sequence: NC_000002.12. See, e.g., Figueiredo-Pontes et al JThorac Oncol. 2014 February; 9(2): 248-253.

The CDKN2A gene resides on chromosome 9 at the band 9p21 and contains 8exons. This gene encodes two proteins, p16and p14ARF, which aretranscribed from the same second and third exons but alternative firstexons: p16 from exon 1α and ARF from exon 1β. As a result, they aretranslated from different reading frames and therefore possesscompletely different amino acid sequences. In addition to p16 and ARF,this gene produces 4 other isoforms through alternative splicing. See,e.g., Stone et al, Cancer Res. 1995 55: 2988-2994. The sequence of thehuman CDKN2A gene and its structure are set forth in entry 1029 inNCBI's gene database; NCBI Reference Sequence: NG_007485.1.

The NFE2L2 gene encodes nuclear factor (erythroid-derived 2)-like 2,also known as NFE2L2 or Nrf2. The NFE2L2 gene is located on 2q31. NFE2L2gene contains 5 exons and spans over 11 kb. The first intron is over 6kb long. See, e.g., Moi et al Proc. Nat. Acad. Sci. 1994 91: 9926-9930.The sequence of the human NFE2L2 gene and its structure are set forth inentry 4780 in NCBI's gene database; NCBI Reference Sequence:NM_001145412.3.

The PTEN gene encodes phosphatase and tensin homolog (PTEN). The gene isthought to contain about 12 distinct introns, and transcription of thegene produces 12 different mRNAs, 7 alternatively spliced variants and 5unspliced forms. The gene is located at chromosome 10q23. See, e.g., Liet al Science 1997 275: 1943-7. The sequence of the human PTEN gene andits structure are set forth in entry 5728 in NCBI's gene database; NCBIReference Sequence: NG_007466.2.

The STK11 gene, also known as LKB1 or PJS, encodes Serine/threoninekinase 11 (STK11) also known as liver kinase B1 (LKB1) or renalcarcinoma antigen NY-REN-19. The gene is located within a region onchromosome 19p13.3 and is thought to contain 18 distinct introns. See,e.g., Masuda et al Hum Genome Var. 2016 3: 16002. The sequence of thehuman STK11 gene and its structure are set forth in entry 6794 in NCBI'sgene database; NCBI Reference Sequence: NG_007460.2.

The sequencing step may be done using any convenient next generationsequencing method and may result in at least 10,000, at least 50,000, atleast 100,000, at least 500,000, at least 1 M at least 10 M at least 100M or at least 1B sequence reads. In some cases, the reads are paired-endreads. As would be apparent, the primers used for amplification may becompatible with use in any next generation sequencing platform in whichprimer extension is used, e.g., Illumina's reversible terminator method,Roche's pyrosequencing method (454), Life Technologies' sequencing byligation (the SOLiD platform), Life Technologies' Ion Torrent platformor Pacific Biosciences' fluorescent base-cleavage method. Examples ofsuch methods are described in the following references: Margulies et al(Nature 2005 437: 376-80); Ronaghi et al (Analytical Biochemistry 1996242: 84-9); Shendure (Science 2005 309: 1728); Imelfort et al (BriefBioinform. 2009 10:609-18); Fox et al (Methods Mol Biol. 2009;553:79-108); Appleby et al (Methods Mol Biol. 2009; 513:19-39) English(PLoS One. 2012 7: e47768) and Morozova (Genomics. 2008 92:255-64),which are incorporated by reference for the general descriptions of themethods and the particular steps of the methods, including all startingproducts, reagents, and final products for each of the steps. Nanoporesequencing could be employed in certain cases.

In some embodiments, the patient may have a cancer that isimmunologically mediated, such as lung cancer including non-small celllung cancer (NSCLC) or small cell lung cancer, melanoma, renal cellcarcinoma or a lymphoma. In some cases, the patient may not have colon,breast, prostate, pancreas, or liver cancer (which are not generallysusceptible to immunotherapy).

In some embodiments, the method may comprise providing a reportindicating whether there are: i. nucleotide transversions in the codingsequences of TP53 and KRAS, relative to reference sequences of TP53 andKRAS, and, optionally, ii. predicted loss of function mutations in PTENand STK11, iii. activating mutations in EGFR and BRAF, and/or iv.rearrangements in ALK and ROS1. In addition or in the alternative, thereport may indicate a score based on the foregoing analysis thatindicates the likelihood that a patient will be responsive to therapy byan immune checkpoint inhibitor. The score may be numerical oralphabetical, or may use descriptors such as “high”, medium” or “low”,or symbols such as “+++”, “++”, “+” or “−”, for example). In someembodiments, a report may provide options for approved (e.g., FDAapproved) therapies, e.g., immune checkpoint inhibitors, for cancersthat are associated with the mutation(s) identified in the sample. Thisinformation can guide treatment decisions made by a physician,

In some embodiments, the report may be in an electronic form, and themethod comprises forwarding the report to a remote location, e.g., to adoctor or other medical professional to help identify a suitable courseof action, e.g., to identify a suitable therapy for the subject. Thereport may be used along with other metrics to determine whether thesubject may be susceptible to immune checkpoint inhibition.

In any embodiment, a report can be forwarded to a “remote location”,where “remote location,” means a location other than the location atwhich the sequences are analyzed. For example, a remote location couldbe another location (e.g., office, lab, etc.) in the same city, anotherlocation in a different city, another location in a different state,another location in a different country, etc. As such, when one item isindicated as being “remote” from another, what is meant is that the twoitems can be in the same room but separated, or at least in differentrooms or different buildings, and can be at least one mile, ten miles,or at least one hundred miles apart. “Communicating” informationreferences transmitting the data representing that information aselectrical signals over a suitable communication channel (e.g., aprivate or public network). “Forwarding” an item refers to any means ofgetting that item from one location to the next, whether by physicallytransporting that item or otherwise (where that is possible) andincludes, at least in the case of data, physically transporting a mediumcarrying the data or communicating the data. Examples of communicatingmedia include radio or infra-red transmission channels as well as anetwork connection to another computer or networked device, and theinternet, including email transmissions and information recorded onwebsites and the like. In certain embodiments, the report may beanalyzed by an MD or other qualified medical professional, and a reportbased on the results of the analysis of the sequences may be forwardedto the patient from which the sample was obtained.

In some embodiments, the method may comprise providing at least oneoption for a treatment by an immune checkpoint inhibitor based on: (i)whether there are nucleotide transversions in the coding sequences ofTP53 and KRAS, and, optionally, CDKN2A and NFE2L2, (ii) whether thereare any loss of function mutations in PTEN and STK11, (iii) whetherthere are any activating mutations in EGFR and BRAF, and (iv) whetherthere are any rearrangements in ALK and ROS1.

In some embodiments, a patient may be selected for treatment by animmune checkpoint inhibitor if the total number of nucleotidetransversions is above a threshold and there are no predicted loss offunction mutations in PTEN and STK11, no activating mutations in EGFRand BRAF, and no rearrangements in ALK and ROS1. For example, if thetotal number of nucleotide transversions is high relative to otherpatients and there are no loss of function mutations in PTEN and STK11,no activating mutations in EGFR and BRAF, and no rearrangements in ALKand ROS1, then the patient may be selected for immune checkpointtherapy. In these embodiments, even a single nucleotide transversion canindicate that the patient is susceptible to immune checkpoint therapy.As such, in some embodiments, the threshold can be 1. In otherembodiments, the patient will only be recommended for immune checkpointtherapy if there are at least 1, at least 2, at least 3, at least 4, atleast 5, or at least 10 nucleotide transversions.

The method described above and below may comprise determing whetherthere are or counting the total number of A to T transversions,determing whether there are or counting the total number of T to Atransversions, determing whether there are or counting the total numberof A to C transversions, determing whether there are or counting thetotal number of C to A transversions, determing whether there are orcounting the total number of G to T transversions, determing whetherthere are or counting the total number of T to G transversions, anddeterming whether there are or counting the total number of G to Ctransversions, or any combination thereof (e.g., determing whether thereare or counting the total number of A to T, T to A, A to C and C to Atransversions).

Also provided is a method for treating cancer. In this method, themethod may comprise: (a) determining, in a sample of cfDNA from a cancerpatient: (i) whether there are nucleotide transversions in the codingsequences of TP53 and KRAS, and, optionally, CDKN2A and NFE2L2, (ii)whether there are any loss of function mutations in PTEN and STK11,(iii) whether there are any activating mutations in EGFR and BRAF, and(iv) whether there are any rearrangements in ALK and ROS1, or receivinga report indicating the same, where this analysis may be done using themethod described above; and (b) identifying the patient as a candidatefor treatment with an immune checkpoint inhibitor if there are one ormore nucleotide transversions in the coding sequences of TP53 or KRAS,no predicted loss of function mutations in PTEN and STK11, no activatingmutations in EGFR and BRAF, and no rearrangements in ALK and ROS1. Insome embodiments, the method may comprise administering the immunecheckpoint inhibitor to the patient.

In this method, the immune checkpoint inhibitor may be an antibody,e.g., an anti-CTLA-4 antibody, anti-PD1 antibody, an anti-PD-L1antibody, an anti-TIM-3 antibody, an anti-VISTA antibody, an anti-LAG-3antibody, an anti-IDO antibody, or an anti-KIR antibody, although othersare known. In some embodiments, the immunotherapy may also include aco-stimulatory antibody such as an antibody against CD40, GITR, OX40,CD137, or ICOS, for example. In some embodiments, the antibody may be ananti-PD-1 antibody, an anti-PD-L1 antibody or an anti-CTLA-4 antibody.Examples of such antibodies include, but are not limited to: Ipilimumab(CTLA-4), Nivolumab (PD-1), Pembrolizumab (PD-1), Atezolizumab (PD-L1),Avelumab (PD-L1), and Durvalumab (PD-L1). These therapies may becombined with one another with other therapies. In some embodiments, thedose administered may be in the range of 1 mg/kg to 10 mg/kg, or in therange of 50 mg to 1.5 g every few weeks (e.g., every 3 weeks), dependingon the weight of the patient.

In certain embodiments, the patient will be treated with the immunecheckpoint inhibitor without knowing the PD1, CTLA-4, TIM-3, VISTA,LAG-3, IDO or KIR status of the tumor.

Also provided is a method for monitoring treatment of a cancer that hasbeen treated with an immune checkpoint inhibitor. In some embodiments,the method may comprise (a) determining the allele frequency (AF) ofnucleotide transversions in the coding sequences of at least TP53 andKRAS (e.g., at least TP53, KRAS, CDKN2A and NFE2L2) in a sample of cfDNAfrom a cancer patient at a first time point, or receiving a reportindicating the same; (b) determining the allele frequency (AF) ofnucleotide transversions in the same coding sequences in a sample ofcfDNA from the cancer patient at a second time point, or receiving areport indicating the same; and (c) comparing the AF of nucleotidetransversions at the first time point to the AF of nucleotidetransversions at the second time point, thereby monitoring the treatmentof the cancer. A decrease in the AF of nucleotide transversions of atleast 30% (e.g., at least 40% or at least 50%) indicates that thepatient is responsive to the immune checkpoint inhibitor and a decreaseof less than 30% or an increase in the AF nucleotide transversions orincreases in the AF of nucleotide transitions indicates that the patientis not responding to the immune checkpoint inhibitor.

A method for predicting a phenotype, comprising: (a) analyzing thenucleotide tranversions and/or transitions from a plurality of cfDNAsamples using the method, wherein the cfDNA samples are isolated fromdifferent patients having a known phenotype; and (b) identifyingnucleotide tranversions that correlate with the phenotype. The phenotypemay be a disease, condition or clinical outcome. The nucleotidetranversions and/or transitions may be diagnostic, prognostic ortheranostic. In some embodiments, this method may comprise comparing thedistribution of nucleotide tranversions or transitions from a firstpatient population that is responsive to an immune checkpoint inhibitorto the distribution of nucleotide tranversions or transitions from apatient population that is non-responsive to an immune checkpointinhibitor and, optionally, estimating the goodness of fit for each ofthe distributions in order to predict predict the response status. Insome embodiments, the method may comprise (i) comparing the computeddistribution of transversion/transition in each patient in two referencepopulations of responders/non-responder (ii) and estimating thegoodnessof-fit of the data to each of these two populations is estimatedin order to quantitatively predict the response status.

As would be readily appreciated, many steps of the method, e.g., thesequence processing steps and the generation of a report indicating thetotal number of transversions, may be implemented on a computer. Assuch, in some embodiments, the method may comprise executing analgorithm that calculates the likelihood of whether a patient will beresponsive to immune checkpoint inhibitor based on: (i) whether thereare nucleotide transversions in the coding sequences for at least TP53and KRAS (e.g., TP53, KRAS, CDKN2A and NFE2L2) or the total number ofthe same and, optionally, (ii) whether there are any loss of functionmutations in PTEN and STK11, (iii) whether there are any activatingmutations in EGFR and BRAF, and (iv) whether there are anyrearrangements in ALK and ROS1, and outputting the likelihood. In someembodiments, this method may comprise inputting the sequences into acomputer and executing an algorithm that can calculate the likelihoodusing the input measurements.

In computer-related embodiments, a system may include a computercontaining a processor, a storage component (i.e., memory), a displaycomponent, and other components typically present in general purposecomputers. The storage component stores information accessible by theprocessor, including instructions that may be executed by the processorand data that may be retrieved, manipulated or stored by the processor.

The storage component includes instructions for providing a score usingthe measurements described above as inputs. The computer processor iscoupled to the storage component and configured to execute theinstructions stored in the storage component in order to receive patientdata and analyze patient data according to one or more algorithms. Thedisplay component may display information regarding the diagnosis of thepatient.

The storage component may be of any type capable of storing informationaccessible by the processor, such as a hard-drive, memory card, ROM,RAM, DVD, CD-ROM, USB Flash drive, write-capable, and read-onlymemories. The processor may be any well-known processor, such asprocessors from Intel Corporation. Alternatively, the processor may be adedicated controller such as an ASIC.

The instructions may be any set of instructions to be executed directly(such as machine code) or indirectly (such as scripts) by the processor.In that regard, the terms “instructions,” “steps” and “programs” may beused interchangeably herein. The instructions may be stored in objectcode form for direct processing by the processor, or in any othercomputer language including scripts or collections of independent sourcecode modules that are interpreted on demand or compiled in advance.

Data may be retrieved, stored or modified by the processor in accordancewith the instructions. For instance, although the diagnostic system isnot limited by any particular data structure, the data may be stored incomputer registers, in a relational database as a table having aplurality of different fields and records, XML documents, or flat files.The data may also be formatted in any computer-readable format such as,but not limited to, binary values, ASCII or Unicode. Moreover, the datamay comprise any information sufficient to identify the relevantinformation, such as numbers, descriptive text, proprietary codes,pointers, references to data stored in other memories (including othernetwork locations) or information which is used by a function tocalculate the relevant data.

EMBODIMENTS Embodiment 1

A method for treating a patient with an immune checkpoint inhibitor,wherein the patient is suffering from cancer, the method comprising:

(a) obtaining or having obtained a sample of blood from the patient;

(b) performing or having performed a sequencing assay on cell-free DNA(cfDNA) from the sample to determine if the cell-free DNA comprises oneor more nucleotide transversions in the coding sequences of TP53 andKRAS, relative to reference sequences of TP53 and KRAS; and

(c) if the patient has one or more nucleotide transversions in thecoding sequences of TP53 and KRAS, then administering an effectiveamount of the immune checkpoint inhibitor to the patient.

Embodiment 2

The method of embodiment 1, wherein the sequencing assay furtherdetermines if the cell-free DNA comprises one or more nucleotidetransversions in the coding sequences of CDKN2A and NFE2L2.

Embodiment 3

The method of any prior embodiment, wherein the method comprises:

(a) obtaining or having obtained a sample of blood from the patient;

(b) performing or having performed a sequencing assay on cell-free DNA(cfDNA) from the sample to determine if the cell-free DNA comprises:

-   -   i. nucleotide transversions in the coding sequences of TP53 and        KRAS, relative to reference sequences of TP53 and KRAS, and    -   ii. predicted loss of function mutations in PTEN and STK11, and

(c) if the patient has one or more nucleotide transversions in thecoding sequences of TP53 and KRAS, and no predicted loss of functionmutations in PTEN and STK11, then administering an effective amount ofthe immune checkpoint inhibitor to the patient.

Embodiment 4

The method of any prior embodiment, wherein the method comprises:

(a) obtaining or having obtained a sample of blood from the patient;

(b) performing or having performed a sequencing assay on cell-free DNA(cfDNA) from the sample to determine if the cell-free DNA comprises:

-   -   i. nucleotide transversions in the coding sequences of TP53 and        KRAS, relative to reference sequences of TP53 and KRAS,    -   ii. predicted loss of function mutations in PTEN and STK11,    -   iii. activating mutations in EGFR and BRAF, and    -   iv rearrangements in ALK and ROS1; and

(c) if the patient has one or more nucleotide transversions in thecoding sequences of TP53 and KRAS, no predicted loss of functionmutations in PTEN and STK11, no activating mutations in EGFR and BRAFand no rearrangements in ALK and ROS1, then administering an effectiveamount of the immune checkpoint inhibitor to the patient.

Embodiment 5

The method of any prior embodiment, wherein the patient has non-smallcell lung cancer (NSCLC).

Embodiment 6

The method of any prior embodiment, wherein the method comprises:

receiving a report indicating that there is at least one transversion inTP53 or KRAS and, optionally, whether there are any loss of functionmutations in PTEN or STK11, whether there are activating mutations inEGFR or BRAF and/or whether there are rearrangements in ALK or ROS1, ora score indicating the same.

Embodiment 7

The method of any prior embodiment, wherein the the sequencing assay isdone by:

(i) amplifying the coding sequences of the genes in a multiplex PCRreaction in which at least 10 amplicons are amplified; and

(ii) sequencing the amplicons.

Embodiment 8

The method of any prior embodiment, wherein the sequencing assaycomprises determining if there are A to T transversions, determining ifthere are T to A transversions, determining if there are A to Ctransversions, determining if there are C to A transversions,determining if there are G to T transversions, determining if there areT to G transversions, determining if there are G to C transversions, anddetermining if there are C to G transversions

or any combination thereof.

Embodiment 9

The method of any prior embodiment, wherein the immune checkpointinhibitor is an antibody.

Embodiment 10

The method of embodiment 9, wherein the antibody is an anti-CTLA-4antibody, anti-PD1 antibody, an anti-PD-L1 antibody, an anti-TIM-3antibody, an anti-VISTA antibody, an anti-LAG-3 antibody, an anti-IDOantibody, or an anti-KIR antibody.

Embodiment 11

The method of any of embodiments 9 or 10, wherein the antibody is ananti-PD-1 antibody or an anti-PD-L1 antibody.

Embodiment 12

A method for analyzing cell free DNA (cfDNA) from the bloodstream of acancer patient, comprising:

(a) sequencing at least part of the coding sequences of TP53 and KRAS ina sample of the cfDNA;

(b) analyzing the sequences obtained in step (a) to identify nucleotidetransversions in the coding sequences of the genes, relative toreference sequences of the genes.

Embodiment 13

The method of embodiment 12, further comprising:

(c) counting the total number of nucleotide transversions identified instep (b).

Embodiment 14

The method of embodiments 12 or 13, wherein step (a) comprises:sequencing at least part of the coding sequences of TP53, KRAS, and,optionally, CDKN2A and NFE2L2 in the sample of cfDNA.

Embodiment 15

The method of any of embodiments 12-14, wherein the method comprises:

(d) sequencing at least part of the coding sequences of PTEN and STK11in the sample of cfDNA and analyzing the sequences to determine if thereare any loss of function mutations in PTEN or STK11;

(e) sequencing at least part of the coding sequences of EGFR and BRAF inthe sample of cfDNA and analyzing the sequences to determine if thereare any activating mutations in EGFR or BRAF; and

(f) sequencing at least part of ALK and ROS1 in the sample of cfDNA andanalyzing the sequences to determine if there are any rearrangements inALK or ROS1.

Embodiment 16

The method of any of embodiments 12-15, wherein the patient hasnon-small cell lung cancer (NSCLC).

Embodiment 17

The method of any of embodiments 12-16, further comprising:

providing a report indicating the number of transversions in the genesof step (a) and, optionally, whether there are any loss of functionmutations in PTEN or STK11, whether there are activating mutations inEGFR or BRAF and/or whether there are rearrangements in ALK or ROS1, ora score indicating the same.

Embodiment 18

The method of any of embodiments 12-16, further comprising:

providing a report indicating that there are transversions in the genesof step (a) and, optionally, whether there are any loss of functionmutations in PTEN or STK11, whether there are activating mutations inEGFR or BRAF and/or whether there are rearrangements in ALK or ROS1, ora score indicating the same.

Embodiment 19

The method of embodiment 17 or 18, further comprising forwarding thereport to remote location.

Embodiment 20

The method of any of embodiments 12-19, further comprising providing arecommendation for a treatment by an immune checkpoint inhibitor basedon:

(i) whether there are nucleotide transversions in the coding sequencesof the genes of (a) and

(ii) whether there are any loss of function mutations in PTEN and STK11,

(iii) whether there are any activating mutations in EGFR and BRAF, and

(iv) whether there are any rearrangements in ALK and ROS1;

wherein treatment by an immune checkpoint inhibitor is recommended ifthere are tranversions in the coding sequences of the genes of (a),there are no predicted loss of function mutations in PTEN and STK11,there are no activating mutations mutations in EGFR and BRAF; and thereare no rearrangements in ALK and ROS1.

Embodiment 21

The method of any of embodiments 12-19, further comprising providing anoption for treatment with an approved treatment by an immune checkpointinhibitor based on:

(i) whether there are nucleotide transversions in the coding sequencesof the genes of (a) and

(ii) whether there are any loss of function mutations in PTEN and STK11,

(iii) whether there are any activating mutations in EGFR and BRAF, and

(iv) whether there are any rearrangements in ALK and ROS1,

wherein treatment by an immune checkpoint inhibitor is listed as anoption if there are tranversions in the coding sequences of the genes of(a), there are no predicted loss of function mutations in PTEN andSTK11, there are no activating mutations mutations in EGFR and BRAF; andthere are no rearrangements in ALK and ROS1.

Embodiment 22

The method of any of embodiments 12-21, wherein the sequencing is doneby:

(i) amplifying the coding sequences of the genes in a multiplex PCRreaction in which at least 10 amplicons are amplified; and

(ii) sequencing the amplicons.

Embodiment 23

The method of any of embodiments 12-22, wherein the counting step (c)comprises counting the total number of A to T transversions, countingthe total number of T to A transversions, counting the total number of Ato C transversions, counting the total number of C to A transversions,counting the total number of G to T transversions, counting the totalnumber of T to G transversions, counting the total number of G to Ctransversions, and counting the total number of C to G transversions, orany combination thereof.

Embodiment 24

The method of any of embodiments 12-23, wherein the counting step (c)comprises determining if there are A to T transversions, determining ifthere are T to A transversions, determining if there are A to Ctransversions, determining if there are C to A transversions,determining if there are G to T transversions, determining if there areT to G transversions, determining if there are G to C transversions, anddetermining if there are C to G transversions, or any combinationthereof.

Embodiment 25

A method for treating cancer, comprising:

(a) determining, in a sample of cfDNA from a cancer patient:

-   -   (i) whether there are any nucleotide transversions in the coding        sequences of at least part of the coding sequences of TP53 and        KRAS; and    -   (ii) whether there are any loss of function mutations in PTEN        and STK11, or receiving a report indicating the same; and    -   (b) identifying the patient as a candidate for treatment with an        immune checkpoint inhibitor if there are nucleotide        transversions and there are no predicted loss of function        mutations in PTEN and STK11.

Embodiment 26

The method of embodiment 25, wherein the patient is identified as acandidate for treatment with an immune checkpoint inhibitor if there aretranversions in the coding sequences of the genes of (a), there are nopredicted loss of function mutations in PTEN and STK11, there are noactivating mutations mutations in EGFR and BRAF; and there are norearrangements in ALK and ROS1.

Embodiment 27

The method of embodiment 26, further comprising administering the immunecheckpoint inhibitor to the patient.

Embodiment 28

The method of embodiments 27, wherein the immune checkpoint inhibitor isan antibody.

Embodiment 29

The method of any of embodiments 26-28, wherein the antibody is ananti-CTLA-4 antibody, anti-PD1 antibody, an anti-PD-L1 antibody, ananti-TIM-3 antibody, an anti-VISTA antibody, an anti-LAG-3 antibody, ananti-IDO antibody, or an anti-KIR antibody.

Embodiment 30

The method of any of embodiments 26-29, wherein the antibody is a PD-1antibody or PD-L1 antibody.

Embodiment 31

The method of any of embodiments 26-30, wherein the cancer patient hasnon-small cell lung cancer.

Embodiment 32

The method of any of embodiments 26-31, wherein the report indicates thetotal number of nucleotide transversions in the at least part of thecoding sequences of at least TP53 and KRAS, CDKN2A and NFE2L2, or ascore indicating the same.

Embodiment 33

The method of any of embodiments 26-32, wherein the total number ofnucleotide transversions of (a)(i) is the sum of the total number of Ato T transversions, the total number of T to A transversions, the totalnumber of A to C transversions, the total number of C to Atransversions, the total number of G to T transversions, the totalnumber of T to G transversions, the total number of G to Ctransversions, and the total number of C to G transversions.

Embodiment 34

The method of any of embodiments 26-33, wherein the sequencing alsocomprises a set of non-coding sequences.

Embodiment 35

A method for monitoring treatment of a cancer that has been treated withan immune checkpoint inhibitor, comprising:

(a) determining the allele frequency of one or more nucleotidetransversions in the coding sequences of at least TP53 and KRAS in asample of cfDNA from a cancer patient at a first time point, orreceiving a report indicating the same;

(b) determining the allele frequency of the one or more nucleotidetransversions in the coding sequences of at least TP53 and KRAS in asample of cfDNA from the cancer patient at a second time point, orreceiving a report indicating the same; and

(c) comparing the allele frequency of the one or more nucleotidetransversions at the first time point to the allele frequency of the oneor more nucleotide transversions at the second time point, therebymonitoring the treatment of the cancer.

Embodiment 36

The method of embodiment 36, wherein, a decrease in the allele frequencyof nucleotide transversions of at least 30% indicates that the patientis responding to the immune checkpoint inhibitor and a decrease of lessthan 30% or an increase in the allele frequency of nucleotidetransversions indicates that the patient is not responding to the immunecheckpoint inhibitor.

Embodiment 37

The method of any of embodiments 35-36, wherein the steps (a) and (b)comprise determining the allele frequency of nucleotide transversions inthe coding sequences of at least TP53, KRAS, CDKN2A and NFE2L2.

Embodiment 38

A method for predicting a phenotype, comprising:

(a) analyzing the nucleotide tranversions and/or transitions from aplurality of cfDNA samples using the method of any of embodiments 12-24,wherein the cfDNA samples are isolated from different patients having aknown phenotype; and

(b) identifying nucleotide tranversions, or a number of the same, thatcorrelate with the phenotype.

Embodiment 39

The method of embodiment 38, wherein the phenotype is a disease,condition or clinical outcome.

Embodiment 40

The method of embodiment 39, wherein the nucleotide tranversions and/ortransitions are diagnostic, prognostic or theranostic.

Embodiment 41

The method of any of embodiments 38-40, wherein the method comprises:

comparing the distribution of nucleotide tranversions or transitionsfrom a first patient population that is responsive to an immunecheckpoint inhibitor to the distribution of nucleotide tranversions ortransitions from a patient population that is non-responsive to animmune checkpoint inhibitor.

Embodiment 42

The method of embodiment 41, further comprising estimating the goodnessof fit for each of the distributions in order to predict predict theresponse status.

EXAMPLES

Aspects of the present teachings can be further understood in light ofthe following examples, which should not be construed as limiting thescope of the present teachings in any way.

Example 1 Identification of Specific Genomic Alterations and Associationwith Clinical Benefit to PD-1/PD-L1 Targeting Therapies

Cell-free DNA (cfDNA) was extracted from plasma isolated from patients'blood collected prior to initial treatment with PD-1/PD-L1 targetingtherapies such as nivolumab or atezolimumab for advanced stage NSCLC.Genomic alterations present in the circulating tumor DNA (ctDNA)fraction of cfDNA were identified using the InVision™ Amplicon-basedplasma NGS platform which sequences the target genes of interests usinggene specific primers designed to hotspots and entire coding regions.Sequencing files were analysed using Inivata's proprietary SomaticMutation Analysis (ISoMA) pipeline. Mutations were detected and reportedsuch as those in FIG. 2. Mutations were classified as a transitionmutation if they were a C>T, T>C, A>G or G>A change. They wereclassified as a transversion if they were an A>C, C>A, G>T, T>G, A>T,T>A, G>C or C>G change.

Example 2 Efficacy of Nivolumab in Patients with High Vs Low Score

In the following examples, the terms “High” and “Low” are used toindicate a patient's responsiveness to immune checkpoint inhibition byan anti-PD-1 or an anti-PD-L1 antibody. A patient assigned a “High”score has a higher likelihood of responding to immune checkpointinhibition by an anti-PD-1 or an anti-PD-L1 antibody whereas a patientassigned a “Low” score has a higher likelihood of responding to immunecheckpoint inhibition by an anti-PD-1 or an anti-PD-L1 antibody.

Plasma from 45 patients diagnosed with advanced stage NSCLC undergoingtreatment for progressive disease with nivolumab was analyzed using theInVision™ NGS platform to characterize alterations in ctDNA. Sampleswere assigned either an High (n=20) or Low (n=25) score based on thealgorithm described in FIG. 1 as outlined above and below. Patients withno detectable ctDNA were classified as indeterminant. Patients withactionable EGFR or BRAF mutations, or either ALK or ROS1 fusions wererecommended targeted therapy and classified as Low. Patients withpredicted loss of function mutations in genes PTEN or STK11 detectedwere classified as Low. Of the remaining patients, those identified withthe presence of transversions in the target list of genes (TP53, KRAS,CDKN2A, NFE2L2) were classified as High. The remaining patients withjust transition mutations were classified as Low. Patients with a Highscore (transversions) showed significantly longer progression-freesurvival than patients with an Low score (lack of transversions) whentreated with nivolumab (FIG. 3).

Example 3 Monitoring Response to Therapy

In this example, serial plasma samples were collected beginning at baseline prior to initial therapy and then subsequent collections over aperiod of 2 months. Changes from base line in the allele frequency (AF)of genomic alterations in ctDNA were calculated and plotted as shown. Inthe first figure from a patient who demonstrated progressive diseasewhile on therapy with atezolimumab, ctDNA AFs increased >2-fold frombaseline to week 2 (FIG. 4).

In contrast, a patient treated with nivolumab who demonstrated anapproximately 2× reduction in the allele frequency of a TP53transversion by day 41 of initiating therapy demonstrated a clinicalpartial response with a progression-free survival interval of 10 months(FIG. 5).

Example 4 Sequencing Method

Patients identified with stage IIIB/IV NSCLC are consented for bloodcollection for analysis prior to receipt of immunotherapy withPD-1/PD-L1 targeting therapy and when feasible, serial samples arecollected prior to receiving additional doses at 2-3 week intervals.

Whole blood is collected into Streck Blood collection tubes (StreckBCT). Upon collection, the Streck BCTs are gently inverted 8-10 timesbefore being shipped immediately. Within 7 days they are centrifuged at1600×g for 10 minutes at room temperature, plasma is removed,transferred to a new tube and then a 2nd centrifugation step isperformed at 20,000×g for 10 minutes to pellet any remaining cellulardebris before transferring the plasma to a new tube. Upon completion ofprocessing all cfDNA samples are frozen at −80° C. until ready foranalysis.

Cell free DNA is extracted from plasma using the QIAamp CirculatingNucleic Acid kit (Qiagen). Digital PCR is then performed using theBioRad QX200 and an assay targeting a 108 bp region of the ribonucleaseP/MRP subunit p30 (RPP30) gene.

Between 2,000 and 16,000 amplifiable copies (as measured by digital PCR)are then used to setup a sequencing library. PCR Primers targeting AKT1,ALK, BRAF, CCND1, CDKN2A, CTNNB1, EGFR, ERBB2, ESR1, FGFR1, FGFR2,FGFR3, GATA3, GNA11, GNAQ, GNAS, HRAS, IDH1, IDH2, KIT, KRAS, MAP2K1,MET, MYC, NFE2L2, NRAS, NTRK1, NTRK3, PDGFRA, PIK3CA, PPP2R1A, PTEN,ROS1, STK11, TP53 and U2AF1 are multiplexed together. These are used toamplify these 36 genes from the cell free DNA. Following PCR, theproducts are cleaned up using SPRIselect reagent (Beckman CoulterB23319) using the manufacturers protocol. DNA is then eluted in 18 uL. Asecond round of PCR is performed targeting sequences added during thefirst PCR. Each primer pair contains a unique barcode combination toenable subsequent sample demultiplexing.

The PCR product was cleaned up once using SPRIselect reagent (BeckmanCoulter B23319) using the manufacturers protocol. Indexed samples arepooled into a tube containing 10 uL 10 mM Tris-HCl pH 8. Samples arethen size selected for 195-350 bp using a 2% Agarose Dye Free cassetteand marker L on the Pippin Prep (Sage Science), following themanufacturer's instructions. Size selected DNA is quantified by Qubit,following the manufacturer's instructions. Quantified libraries aresequenced on the NextSeq500 Illumina platform (300 cycle PE) with 5%PhiX to monitor sequencing performance and data analysis is performed.

Sequencing files are analyzed using the Inivata Somatic MutationAnalysis (ISoMA) pipeline to identify SNVs, CNVs and indels. In theISoMA pipeline a minimum Phred quality score of 30 for each base isrequired for inclusion in the analytics. For SNV and indel analysis, abackground model is first established using samples from presumedhealthy donors for each position/base pair change covered by our panel.The final determination of an SNV call integrates the data acrossmultiple replicates for each sample in comparison with this backgroundwithin a maximum likelihood framework. The same statistical principle isused for indels using samples from the same analytical batch in order toenable appropriate background calibration. The minimum depth at whichany SNV or indel would be called is 1000×.

Mutations are classified as a transition mutation if they are a C>T,T>C, A>G or G>A change. They are classified as a transversion if theyare an A>C, C>A, G>T, T>G, A>T, T>A, G>C or C>G. Patients withactionable EGFR or BRAF mutations, or either ALK or ROS1 fusions arerecommended targeted therapy and classified as Low. Patients with noctDNA detected or predicted loss of function mutations in PTEN or STK11detected are classified as Low. Of the remaining patients, thoseidentified with the presence of transversions in the target list ofgenes (particularly TP53, KRAS, CDKN2A, and NFE2L2) are classified asHigh. The remaining patients with just transition mutations areclassified as Low.

It will also be recognized by those skilled in the art that, while theinvention has been described above in terms of preferred embodiments, itis not limited thereto. Various features and aspects of the abovedescribed invention may be used individually or jointly. Further,although the invention has been described in the context of itsimplementation in a particular environment, and for particularapplications (e.g. ctDNA analysis) those skilled in the art willrecognize that its usefulness is not limited thereto and that thepresent invention can be beneficially utilized in any number ofenvironments and implementations where it is desirable to examine cfDNA.Accordingly, the claims set forth below should be construed in view ofthe full breadth and spirit of the invention as disclosed herein.

What is claimed is:
 1. A method for treating a patient suffering fromnon-small cell lung cancer with an immune checkpoint inhibitor, whereinthe method comprises: (a) receiving a report indicating the results of asequencing assay, wherein the sequence assay is capable of identifying,in cell-free DNA (cfDNA) from a blood sample from the patient: (i)sequence variations in at least TP53, KRAS, PTEN, STK11, EGFR and BRAFand (ii) rearrangements in at least of ALK and ROS1; (b) identifying thepatient as having one or more nucleotide transversions in the codingsequences of either TP53 or KRAS or in TP53 and KRAS, no predicted lossof function mutations in PTEN or STK11, no activating mutations in EGFRor BRAF and no rearrangements in ALK or ROS1; and (c) administering aneffective amount of the immune checkpoint inhibitor to the patient ofstep (b).
 2. The method of claim 1, wherein the report further comprisesone or more treatment options.
 3. The method of claim 2, wherein thetreatment options include PD-1/PD-L1 immune checkpoint blockade.
 4. Themethod of claim 2, wherein the treatment options include treatment withIpilimumab, Nivolumab, Pembrolizumab, Atezolizumab, Avelumab orDurvalumab.
 5. The method of claim 1, wherein the report comprises ascore indicating the likelihood of whether the patient will respond tothe immune checkpoint inhibitor.
 6. The method of claim 1, wherein theimmune checkpoint inhibitor administered in step (c) is an antibody. 7.The method of claim 6, wherein the antibody is an anti-PD-1 antibody. 8.The method of claim 6, wherein the antibody is an anti-PD-Ll antibody.9. The method of claim 1, wherein the sequencing assay is done by: (i)amplifying the sequences of the genes in a multiplex PCR reaction inwhich at least 10 amplicons are amplified; and (ii) sequencing theamplicons.
 10. The method of claim 1, wherein the sequencing assaycomprises determining if there are any A to C transversions, determiningif there are any C to A transversions, determining if there are any G toT transversions, determining if there are any T to G transversions,determining if there are any A to T transversions, determining if thereare any T to A transversions, determining if there are any G to Ctransversions and determining if there are any C to G transversions inTP53 and KRAS.
 11. The method of claim 1, wherein the activatingmutations in EGFR and BRAF comprise: G719X, exon19 deletions, V765A,T783A, V774A, S784P, L858R and L861X in EGFR and V600E; L601G; K601E;L597V/Q/R and G469V/S/R/E/A in BRAF.
 12. The method of claim 1, whereinthe rearrangements in ALK and ROS1 comprise EML4-ALK, TFG-ALK,KIF5B-ALK, CD74-ROS1, SLC34A2-ROS1, SDC4-ROS1 and EZR-ROS1 fusions.